RU2360634C2 - Method of treatment of fractures of proximal department of humerus and device for its realisation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions concerns medicine, namely to traumatology and orthopedy. The device for treatment of fractures of proximal department of a humerus contains a periosteal element, spokes and screws. The periosteal element is executed in the form of a two-level plate at which the periosteal surface is bent. In a high step of a plate 4 apertures under the spokes which axes converge towards introduction of spokes are executed. Axes of 2 extreme apertures under spokes converge under an angle 30°, and axes of 2 averages - under an angle 20°. The surface of a high step turned to a head of a humeral bone is executed by the bent. In a low step of a plate the oblong aperture under screws is executed. The extremities of spokes located in extreme apertures have possibility of a bend with an support in a wall of a high step of a plate from a low step. The extremities of the spokes located in average apertures have bend possibility in an oblong aperture. The way of treatment of fractures of proximal department of a humeral bone is carried out by means of the above-stated device which is established below the fracture zone on an outside-lateral surface of the distal fragment. The screw is entered through an oblong aperture of the device at level of one of extreme apertures through both cortical layers. The spokes are entered through the extreme apertures to a subchondral zone, other screw is entered into an oblong aperture in the field of the second extreme spoke. The extremities of spokes are bitten off and fixed by a bend of the extremities of spokes with an emphasis in a wall of a high step of a plate from a low step and torsion of screws. The spokes are entered to a subchondral zone through average apertures; the extremities of spokes are cut and bent in an oblong aperture of the plate.

EFFECT: group of inventions provides procollar prevention of the periosteal element and prevention of shift of a proximal fragment of a humerus.

2 cl, 1 ex, 5 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and is directed to the treatment of fractures of the proximal humerus.

Fractures of the proximal humerus account for approximately 5% of all fractures and are one of the most common skeleton injuries. The incidence of such fractures is 75-100 cases per 100,000 population per year. If, in young patients, injuries occur, as a rule, as a result of a high-energy injury and are often represented by multifragmental fractures, then in the elderly they can occur even as a result of indirect trauma with a slight effect of external forces against the background of existing osteoporosis and are two-fragmented. 75% of fractures of the proximal humerus occur in patients over the age of 60, while in women they occur 2-3 times more often than in men.

In recent decades, indications for the use of surgical treatments for fractures of the proximal humerus have expanded significantly. This happened both due to the improvement of surgical technique (wider use of minimally invasive interventions), and due to the appearance of new implants. To fix fractures of the proximal humerus, metal structures are used (plates with angular stability, locking pins, elastic titanium pins), the use of which allows to achieve stability of fragments and to speed up the patient rehabilitation process to a different extent.

Known osteosynthesis with knitting needles. This is a classic method for stabilizing shoulder fractures, which meets modern requirements for minimally invasiveness. An important condition for success is good bone quality, since the fixation of the spokes in the osteoporotic bone is not always reliable, which can lead to their migration and secondary displacements of the fragments. Holding the needles at an acute angle to the bony diaphysis determines the tendency to slide off the bone, which requires the use of special conductors (Kazaev S.Ya., Sitnik A.A. Treatment of fractures of the proximal humerus. - Belarusian Medical Journal No. 3 (13), 2005).

Plate osteosynthesis is also known. If in most periarticular fractures, osteosynthesis with a plate is the method of choice, then with fractures of the proximal humerus, the use of plates is limited. The main disadvantage of this treatment method is a significant number of complications (avascular necrosis of the head, limitation of joint function). Important is not only the accurate reposition of fragments, but also the correct installation of the implant. If the position of the implant is too high, 30-60% of patients, according to various authors, show signs of impingement syndrome after plate osteosynthesis. Keep in mind that plate osteosynthesis requires a fairly wide surgical access, and this is often a limitation in the treatment of elderly patients with severe comorbidity (Margo Anterior No. 5-6 / 2001, pp. 5-15, "The rationale of operative fracture care ". J.Schatzker, M.Tile)

Intramedullary osteosynthesis is also known, in particular in the treatment of two-fragment fractures of the proximal humerus. The use of intramedullary nails with blocking provides a high fixation strength comparable with open plate osteosynthesis. However, the use of intramedullary nails in the treatment of three- and four-fragment fractures of the proximal humerus is limited. The use of titanium elastic pins is also limited: there is insufficient stability of osteosynthesis and the frequency of development of secondary displacements (Margo Anterior No. 5-6 / 2001, pp. 1-4).

Abroad, in recent years, a special guide for knitting needles in the amount of 2 pieces has been used for fractures of the neck of the shoulder - Humerus Block by Synthes (Margo Anterior No. 5-6 / 2001, pp. 1-16). It is a volume washer having 2 channels for knitting needles held at an angle to the head of the humerus. The guide on the peripheral fragment is strengthened. This guide was taken by us as a prototype. At the same time, this device has its drawbacks (2 spokes are insufficient for osteosynthesis, fixing the washer on one screw is the reason for the possible turning of the bone element; complex guides are necessary for the implementation of minimally invasive osteosynthesis, which makes the system bulky and expensive, the latch is not stable enough with concomitant osteoporosis).

The problem to be solved:

- prevention of rotation of the bone element;

- prevention of displacement of the proximal fragment of the humerus.

The tasks are solved using the proposed method and device.

The proposed device for the treatment of fractures of the proximal humerus contains a bone element, spokes and screws. The osseous element is made in the form of a two-stage plate, in which the osseous surface is concave. In the high stage of the plate there are 4 holes for knitting needles, the axes of which converge towards the introduction of the needles. The axes of the 2 outermost holes for the spokes converge at an angle of 30 °, and the axes of the 2 middle ones - at an angle of 20 °. The surface of the high stage facing the head of the humerus is made concave. In the low stage of the plate, an oblong hole for the screws is made. The ends of the spokes located in the extreme holes have the ability to bend with an emphasis on the wall of the high stage of the plate from the side of the low stage. The ends of the spokes located in the middle holes have the ability to bend into an elongated hole.

When implementing the proposed method for the treatment of fractures of the proximal humerus, the above proposed device is used, which is installed below the fracture zone along the outer-lateral surface of the distal fragment. Through an elongated opening of the device at the level of one of the extreme openings, a screw is inserted through both cortical layers. Through the outer holes enter the needles to the subchondral zone. Another screw is introduced into the oblong hole in the region of the second extreme spoke. The ends of the spokes are bitten off and fixed by bending the ends of the spokes with an emphasis on the wall of the high stage of the plate from the side of the low stage and tightening the screws. Through the middle holes, the needles are introduced to the subchondral zone, the ends of the needles bite off and bend into the oblong hole of the plate.

The method is carried out using the device. A special guide is mounted on the peripheral fragment below the fracture zone at a distance of at least 3 cm from the fracture line along the outer lateral surface of the humerus and is fixed with one screw through an oblong hole in the region of one of the outermost holes for the spoke (2 mm in diameter). Through the opposite extreme hole for the needles, a needle is passed into the head of the humerus to the subchondral zone. The needle is bent at the entrance to the hole with an emphasis on the wall of the high stage from the low stage, bite off, leaving 3-4 mm. Next, screw the second screw through an elongated hole and fix the held needle, pressing its end with its head. Next, the first screw is turned out 2-3 mm, releasing the extreme hole through which the second spoke is inserted. It is also bent, bit off and fixed with the screw head. After each introduction of the spokes, their position in the head is controlled by an electron-optical converter. The third and fourth spokes are carried through the middle holes without fixing the screw heads. Their protruding ends at the holes bite off and bend into an oblong hole. The appearance of the retainer mounted on the humerus is shown in figures 1, 2.

Monitoring of the actions carried out by the electron-optical converter as necessary. The wound is sutured in layers, the cast is not applied. In the postoperative period, early activation is carried out, physiotherapy exercises from 3-4 days.

Sutures are removed on the 10-14th day, gradually increase the load of physiotherapy exercises, massage is carried out. X-ray control of the position of the structure and regeneration processes is carried out after 1.5-2 months. Removal of the fixative is carried out in the period from 3 to 6 months after surgery.

To achieve this goal, we have developed a special device for the surgical treatment of fractures of the proximal humerus. The device consists of a two-stage plate (Figure 3, 1), knitting needles and screws. The plate is made concave, in accordance with the curvature of the proximal humerus. In the high step (Figure 3, position 2) there are 4 holes for knitting needles with a diameter of 2 mm. The axis of the outer holes for the needles (Figure 4, position 3) converge at an angle of 30 °, and the axis of the middle (Figure 4, position 4) - at an angle of 20 °. The surface of the high stage facing the head of the humerus is made concave (Figure 5, 5). In the low stage of the plate (Fig. 3, pos. 6), an oblong hole (Fig. 5, pos. 7) is made for the screws. The ends of the spokes located in the extreme holes have the ability to bend with an emphasis on the wall of the high stage of the plate from the side of the low stage. The ends of the spokes located in the middle holes have the ability to bend into an oblong hole.

The proposed method and device allowed to obtain a new technical result. The technical result consists in preventing the rotation of the bone element and preventing the displacement of the proximal fragment of the humerus.

The present invention is not obvious to traumatologists and orthopedists. We first proposed for the treatment of such fractures to use the method of osteosynthesis of the proximal humerus with four spokes with fixation by their bone element. It would seem that a fairly simple technical solution that we proposed for the treatment of fractures of the proximal humerus required a long and painstaking work to analyze treatment practices in this area, as well as creative searches for technical implementation for this operation. The technical solution was improved in the process of developing the optimal design and in the form presented in the application, it is simple and convenient to use.

Our patent search showed that our proposed technical solution is not found in the published literature. Although it is very simple to implement, it nevertheless compares favorably with all previously known methods of treating such fractures.

Example

Patient P., 65 years old, with a closed fracture of the surgical neck of the left humerus with displacement. Upon admission, local anesthesia was performed, closed manual reposition, a plaster cast was applied. On control radiographs, the displacement of fragments was preserved. The patient was operated on - osteosynthesis of the surgical neck of the shoulder was performed with a retainer-guide for the proximal humerus.

Under endotracheal anesthesia in the patient’s position on the back, a linear incision was made 5 cm long along the outer-lateral surface of the left shoulder in the projection of the fracture. The surrounding tissues are bluntly and sharply apart. The fracture zone is exposed. Bone fragments are cleaned, an open reposition of the fracture is made. A retainer-guide is installed 3 cm distal to the fracture site. A hole was drilled into the bones and a cortical screw was inserted through an oblong hole in a low stage. A needle was passed through the opposite extreme hole for the spoke into the head of the humerus to the subchondral zone.

The needle was bent at the entrance to the hole with an emphasis on the wall of the high stage from the side of the low stage, bit off, leaving 3-4 mm. Next, a second screw was screwed through an oblong hole and the held spoke was fixed, pressing its end with its head. The first screw was turned out 2-3 mm, releasing the extreme hole through which the second spoke was inserted. It was also bent, bit off and fixed with the screw head. After each introduction of the spokes, their position in the head was controlled by an electron-optical converter. The third and fourth spokes were carried out through the middle holes without fixing the screw heads. Their protruding ends at the holes were bitten off and bent into an oblong hole.

The control of the ongoing actions was carried out by an electron-optical converter as necessary. The wound was sutured in layers, the cast was not applied. In the postoperative period, early activation was carried out, physiotherapy exercises from 3-4 days. Sutures were removed on day 14. Gradually increased the load of physiotherapy exercises, massage was performed. X-ray control of the position of the structure and regeneration processes was carried out after 1.5 months. The fracture healed after 2.5 months. The latch was removed 4 months after the operation. The function of the left upper limb is satisfactory.

Claims (2)

1. A method of treating fractures of the proximal humerus, characterized in that the device according to claim 2 is used, which is installed below the fracture zone along the outer lateral surface of the distal fragment, a screw is inserted through the cortical layer through the oblong hole of the device at the level of one of the extreme holes , the needles are inserted through the extreme holes to the subchondral zone, another screw is inserted into the oblong hole in the region of the second extreme needle, the ends of the needles are bit off and fixed by bending the ends of the needles with an emphasis in the high stage of the plate from the side of the low stage and tightening the screws, spokes are inserted through the middle holes to the subchondral zone, the ends of the needles are bit off and bent into the oblong hole of the plate. 2. A device for treating fractures of the proximal humerus containing a osseous element, knitting needles, characterized in that it is provided with screws, the osseous element is made in the form of a two-stage plate, in which the osseous surface is concave, in the high stage of the plate there are 4 holes for knitting needles, the axes of which converge towards the introduction of the spokes, the axes of 2 extreme holes for the spokes converge at an angle of 30 °, and the axes of the 2 middle ones at an angle of 20 °, the surface of the high step facing the head of the humerus is made concave, lower stage plate formed an oblong hole for the screws, the ends of spokes arranged in the outer holes have the ability to bend, with emphasis in the high stage side wall of the plate below the level of the ends of spokes arranged in the middle holes have the ability to bend in the elongated hole.

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